HEALTH DECLARATION FORM HEALTH DECLARATION FORM HEALTH DECLARATION FORM

IMPORTANT REMINDER: The information gathered on this form will be IMPORTANT REMINDER: The information gathered on this form will be IMPORTANT REMINDER: The information gathered on this form will be
used only to determine whether you may be infected with COVID-19. used only to determine whether you may be infected with COVID-19. used only to determine whether you may be infected with COVID-19.
fffffff on this form is strictly confidential.
The information The information on this form is strictly confidential. The information on this form is strictly confidential.

FILL OUT ENTRIES IN BOLD LETTERS DATE: ________ FILL OUT ENTRIES IN BOLD LETTERS DATE: ________ FILL OUT ENTRIES IN BOLD LETTERS DATE: ________

PERSONAL DATA: TEMPERATURE: _______ PERSONAL DATA: TEMPERATURE: _______ PERSONAL DATA: TEMPERATURE: _______

Name: ____________________________________________________ Name: ____________________________________________________ Name: ____________________________________________________

Last Name, First Name, Middle Name Last Name, First Name, Middle Name Last Name, First Name, Middle Name

Sex ( ) Male Age: _____ Nationality: _________ Civil Status: _____ Sex ( ) Male Age: _____ Nationality: _________ Civil Status: _____ Sex ( ) Male Age: _____ Nationality: _________ Civil Status: _____
( ) Female ( ) Female ( ) Female
Address: __________________________________________________ Address: __________________________________________________ Address: __________________________________________________
Telephone No./Mobile No. ________________Email Address: _______ Telephone No./Mobile No. ________________Email Address: _______ Telephone No./Mobile No. ________________Email Address: _______

Please check if you have any of the following at present during the past Please check if you have any of the following at present during the past Please check if you have any of the following at present during the past
14 days: 14 days: 14 days:
( ) fever >37.5 ( ) sore throat ( ) diarrhea ( ) fever >37.5 ( ) sore throat ( ) diarrhea ( ) fever >37.5 ( ) sore throat ( ) diarrhea
( ) cough ( ) headache ( ) body aches ( ) cough ( ) headache ( ) body aches ( ) cough ( ) headache ( ) body aches
( ) difficulty of breathing ( ) loss of smell or taste ( ) colds/runny nose ( ) difficulty of breathing ( ) loss of smell or taste ( ) colds/runny nose ( ) difficulty of breathing ( ) loss of smell or taste ( ) colds/runny nose
( )body weakness ( ) fatigue ( ) nausea/vomiting ( )body weakness ( ) fatigue ( ) nausea/vomiting ( )body weakness ( ) fatigue ( ) nausea/vomiting

Please enumerate, if any, cities in the Philippines you have lived, worked, Please enumerate, if any, cities in the Philippines you have lived, worked, Please enumerate, if any, cities in the Philippines you have lived, worked,
transited in the past 14 days ___________________________________________ transited in the past 14 days ___________________________________________ transited in the past 14 days ___________________________________________
Please check the appropriate box: Please check the appropriate box: Please check the appropriate box:
In the last 14 days, have you been in close contact In the last 14 days, have you been in close contact In the last 14 days, have you been in close contact
or exposed to any person suspected of Covid 19? ( ) YES ( ) NO or exposed to any person suspected of Covid 19? ( ) YES ( ) NO or exposed to any person suspected of Covid 19? ( ) YES ( ) NO
Were you confined in a hospital/health care Were you confined in a hospital/health care Were you confined in a hospital/health care
facility during the past 14 days? ( ) YES ( ) NO facility during the past 14 days? ( ) YES ( ) NO facility during the past 14 days? ( ) YES ( ) NO
Have you been diagnosed to have pneumonia in the Have you been diagnosed to have pneumonia in the Have you been diagnosed to have pneumonia in the
Past 14 days? ( ) YES ( ) NO Past 14 days? ( ) YES ( ) NO Past 14 days? ( ) YES ( ) NO
Did you visit any health facility, hospital or clinic in Did you visit any health facility, hospital or clinic in Did you visit any health facility, hospital or clinic in
the past 14 days? ( ) YES ( ) NO the past 14 days? ( ) YES ( ) NO the past 14 days? ( ) YES ( ) NO
Do you have any household members or close contact Do you have any household members or close contact Do you have any household members or close contact
who are currently having fever, cough or any who are currently having fever, cough or any who are currently having fever, cough or any
respiratory problems? ( ) YES ( ) NO respiratory problems? ( ) YES ( ) NO respiratory problems? ( ) YES ( ) NO
In the last 14 days, have you been in contact with In the last 14 days, have you been in contact with In the last 14 days, have you been in contact with
COVID 19 confirmed persons? ( ) YES ( ) NO COVID 19 confirmed persons? ( ) YES ( ) NO COVID 19 confirmed persons? ( ) YES ( ) NO
When did this contact or person tested positive When did this contact or person tested positive When did this contact or person tested positive
for RT-PCR? ______________________________ for RT-PCR? ______________________________ for RT-PCR? ______________________________
Have you undergone any test for SARS-COV2 for the Have you undergone any test for SARS-COV2 for the Have you undergone any test for SARS-COV2 for the
past 14 days? ( ) YES ( ) NO past 14 days? ( ) YES ( ) NO past 14 days? ( ) YES ( ) NO

I hereby certify that the information given is true, correct and complete. I I hereby certify that the information given is true, correct and complete. I I hereby certify that the information given is true, correct and complete. I
understand that failure to answer any questions or falsified response may have understand that failure to answer any questions or falsified response may have understand that failure to answer any questions or falsified response may have
serious consequences. serious consequences. serious consequences.

_________________________ _________________________ _________________________

Signature Signature Signature